IntraPet Ultrasound Patient Information Form

To schedule, please

TEXT: 410-849-6867 or

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DATE OF ULTRASOUND EXAM: Date is CONFIRMED with IntraPet and Owner. This includes same day add-ons. CONFIRMED means clinic and owner have agreed to the ultrasound fee and cancellation policies/fees.

REQUESTED DATES for ultrasound (if not already confirmed with IntraPet, format: month/day).

Notes regarding scheduling may be added here

DVM Name

Hospital Name (No acronyms or #’s) *

Pet Name *

Owner Last Name *

Date of Birth *

Date

Weight (specify lbs or kg) *

Species/Breed *

Sex *

Ultrasound Exam-select all that apply. (Abdominal includes urinary & repro) *

Abdominal Echocardiogram (Heart function) Specialty-Chest, Urinary, Thyr, Preg Procedure-FNA, Centesis, OTHER ECG 6 lead

If Specialty or Procedure specify type:

(Urinary, Thyroid, Chest, Pregnancy, FNA)

Previous IntraPet Ultrasound? *

Date of Previous IntraPet Ultrasound

PLEASE SPECIFY ECHO OR ABD

If concern for second cavity pathology is seen during a scan, (ex: splenic mass, pleural effusion, enlarged abd vessels), a limited second cavity scan is approved at $35 *

Presenting Complaint/History/PE *

PLEASE INCLUDE GRADE OF MURMUR IF APPLIES

Tentative diagnosis/ Questions to be answered with ultrasound *

Brief abnormalities for Lab Results/Radiograph Findings (please upload full results or email intrapetstaff@gmail)

*PLEASE DO NOT INCLUDE ENTIRE MEDICAL CHARTS/VISIT NOTES ETC. LABS/RADS/TEST RESULTS ONLY

Medications with dosage and duration

Sedation is NOT a requirement, it is recommended with some patients to achieve a diagnostic ultrasound, but it is ultimately the decision of DVM and the owner. *Certain sedatives interfere with echocardiograms, please contact us with any questions scan or injection.

Sedation— any instructions can be listed in box below *

YES, IV sedation is approved IF deemed necessary during the ultrasound. We ONLY use sedation if we cannot accomplish a diagnostic scan without it. NO, sedation is declined. I accept the conditions stated below.* YES, Intramuscular sedation — I AGREE TO PAY A FEE IF I DO NOT SEDATE PRIOR TO INTRAPET ARRIVAL. I WILL TEXT INTRAPET THE MORNING OF SCAN FOR ETA.

TEXT NUMBER CONTACT FOR INTRAPET TO PROVIDE SEDATION WINDOW

THIS IS NOT A GUARANTEED WINDOW, IT IS AN ESTIMATE AND MAY CHANGE DURING DAY.

Sedation: please type dosages (or “in medical chart”) and notes regarding sedation. Sedation doses must be available at time of scan.

*CONDITIONS FOR SEDATION CHOICE "NO":

IntraPet will not ask for sedation at the time of the scan if "NO" is selected, even if patient condition prevents a diagnostic scan.

If sedation choice is "NO", this indicates DVM/owner have declined sedation. A partial scan may be submitted at full charge if patient condition prevents a complete diagnostic scan or no scan will be performed and a fee will apply.

Confidential questions/concerns, information for specialist/sonographer. WILL NOT APPEAR ON FINAL REPORT

Lab work / Rads

Yes, employee pet No, not employee pet* Employee name matches patient name.

STAT is approved if emergency and patient is in critical condition. (Please note that preliminary findings may change this answer and will be discussed with DVM) *

YES, patient is critical. Please submit a STAT NO, patient is not critical.

Please enter your Email to receive a PDF copy of this form for your records. Your form will be editable from the link you receive at this email. *

example@example.com

Secondary email if above email is not clinic email.

example@example.com

I have contacted IntraPet by text or separate email to schedule this exam: *

YES, I have contacted IntraPet. NO, I have not contacted IntraPet and will do so after this form submission.

TEXT/CALL 410-849-6867 or EMAIL intrapetstaff@gmail

THANK YOU!

IntraPet Patient Information